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s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209),466-6781 I 1 PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin.Local Health District for a permit to construct and/or install the work herein described. This application is E made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ` �} Job Address 159-75 J O �� e; /pFZ __ City 44 /�77 OPLot Size.60 `6 PM Owner's Name G42o/g�� Address t.f 9 /S SO 7 S 7— Phone 40519-4- 4 �1�_Contractor f Address' License No. Phone TYPE OF WELL/PUMP: NEW WELL_❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ rSYSTEM REPAIR ❑ OTHER ❑ [ DISTANCE TO NEAREST:SEPTIC TANK " SEWER'LINES DISPOSAL FLD. PROP. LINE [ _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F-) Public C] Other F1 Delta Depth of Grout Seal Type of Grout - _ l I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by fi. Repair Work Done ❑ Type of Pump Y H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material,(Below 50') II TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION`) I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: 'Residence_ Commercial)--Other ! Number of living units: Number of bedrooms I . Character of soil to a depth of 3 feet: f t Water table depth SEPTIC TANK ❑ Type/Mfg Capacity—L-- No. Compartments PKG. TREATMENT PLT- ❑ { Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines I _ _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size I Number SUMPS L1 Distance to nearest: r:�Well Foundation 3 Property Line DISPOSAL-PONDS ❑ I hereby certify that I have prepared this application and that the work will_be Sane in_ac`cordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant 0 st call-for all required inspections. mplete drawing an reverse side. Signed X Title: t� +' °' `l Date: E _ FOR DEPARTMENT USE ONLY Application Accepted by A U Date Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: d � ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant.- Return all copies to: Environmental-Health Permit/Services.1601 E. Hazelton Ave., P.O'. Box 2009, Stk., CA 95201FEE t INFO AMOUNT DUE �JAMOU�INT REMITTED CASH RECEIVED BY DATE PERMITNO. 1r t EH 13-24 IREV.1/n 51 C v IA4 EH 14-28, - ✓ l V NI